Prospective evaluation of pericardial catheter placement versus needle pericardiocentesis in the management of canine pericardial effusion.

OBJECTIVE: To compare the safety and efficacy of pericardial catheter placement with needle pericardiocentesis in dogs with pericardial effusion (PE) DESIGN: Prospective, randomized clinical trial. SETTING: University teaching hospital. ANIMALS: Thirty client-owned dogs requiring pericardiocentesis between January 2017 and August 2019. INTERVENTIONS: Dogs were randomized to undergo PE drainage via indwelling pericardial catheter placement (catheter group) followed by elective drainage every 4-6 hours or needle pericardiocentesis (needle group) repeated as necessary. MEASUREMENTS AND MAIN RESULTS: Fifteen dogs were allocated to the catheter group and 15 to the needle group. Data collected included signalment, cause of effusion, occurrence of arrhythmias pre-, during, and post-pericardiocentesis, procedural length, and details of repeated drainages. There was no significant difference between mean procedural times for pericardial catheter placement (17.7 min [±11.8]) and needle pericardiocentesis (12.1 min [±8.6]) (P = 0.192) or the rate of new arrhythmias in the catheter (36%) and needle (64%) groups (P = 0.24). Pericardial catheters were kept in situ for a median of 21 hours (range, 14-85). Three of 15 (20%) dogs in the needle group required repeated pericardiocentesis within 24 hours of initial pericardiocentesis. Pericardial catheters enabled repeated large volume PE drainage in 4 cases (median, 10.6 mL/kg; range, 8-5-10.6). CONCLUSIONS: Pericardial catheters appear to offer a safe alternative to needle pericardiocentesis. Minimal sedation is required for placement, and they can be placed quickly. Their indwelling nature and use was not associated with a higher rate of arrhythmia compared to that of needle pericardiocentesis alone, and may be beneficial in the event that clinically significant PE recurs.

[Pericardiocentesis - step by step]. / Perikardpunktion ­ Schritt für Schritt.

A pericardial effusion can be caused by malignant, infectious and autoimmune diseases or by trauma, such as a coronary artery rupture during a cath procedure. In the case of a cardiac tamponade a pericardiocentesis has to be performed immediately.Additionally, a pericardiocentesis may also be performed for diagnostic purposes. However, since histologic and microbiologic findings are rarely pointing to hitherto unsuspected results, the risk of the procedure must very carefully be weighed against its benefits. The risks of a pericardiocentesis include injuries to the lungs and liver as well as the heart itself, such as puncture of the right ventricle or the rupture of a coronary artery.This article is a step-by-step description of how to safely perform an ultrasound-guided pericardiocentesis.

Cardiac tamponade complicating thoracentesis in a patient after left pneumonectomy: A case report.

RATIONALE: Therapeutic or diagnostic thoracentesis is widely used in different clinical settings. Cardiac injury, a rare complication, could lead to fatal consequences. We describe a case of cardiac tamponade complicating thoracentesis that was recognized and rescued in a timely manner. PATIENT CONCERNS: A 42-year-old woman underwent blind thoracentesis due to excessive left pleural effusion after left pneumonectomy surgery. She suddenly lost consciousness and was in a state of shock a few minutes after needle insertion and fluid drainage. DIAGNOSIS: Bedside transthoracic echocardiography revealed pericardial effusion at a depth of 20 mm, and cardiac tamponade complicating thoracentesis was diagnosed. INTERVENTIONS: After draining 250 mL of non-coagulated blood by pericardiocentesis under transthoracic echocardiography guidance, a tube was placed for continuous drainage over the subsequent 36 hours. OUTCOMES: The patient's hemodynamic condition was stabilized hours after pericardiocentesis. The patient was discharged in good condition a few days later. LESSONS: Imaging assessment and guidance in the process of thoracentesis was indispensable, especially in a patient with altered intra-thoracic anatomy. Cardiac damage, as a life-threatening complication, should be considered once hemodynamic instability occurs during the procedure.

Early versus delayed removal of the pericardial drain in patients with cardiac tamponade complicating radiofrequency ablation of atrial fibrillation.

INTRODUCTION: Cardiac tamponade is a common life-threatening complication during radiofrequency ablation of atrial fibrillation (RAAF) and is mostly managed by pericardiocentesis. Thus far, the optimal timing for drain removal has not been established. METHODS AND RESULTS: We retrospectively enrolled patients with cardiac tamponade complicating RAAF. The ablation was performed with interrupted novel oral anticoagulants, interrupted warfarin or uninterrupted warfarin protocols. An observation period of at least 30 minutes after the last aspiration via the drain was used to monitor the reaccumulation of pericardial fluid, and then, the patients were divided into an early removal (ER) group in the electrophysiology (EP) laboratory and a delayed removal (DR) group in the ward. A total of 51 patients were included: 25 patients in the ER group and 26 patients in the DR group. There were no significant differences in baseline demographics between the two groups, and no cardiac tamponade reoccurred in either group in the ward. Unlike the DR group, the ER group showed an association with a decreased rate of chest pain (P = .000), fever (P = .001), nausea (P = .000), in-hospital recurrent AF (P = .010), and antibiotic use (P = .012). Anticoagulation was earlier (P = .009), and the median in-hospital stay was shorter (P = .001) in the ER group than in the DR group. CONCLUSIONS: ER of the pericardial drain after no evidence of pericardial bleeding for at least 30 minutes in the EP laboratory is safe and associated with a better early hospital course.

"Blind" pericardiocentesis: A comparison of different puncture directions.

BACKGROUND: "Blind" pericardiocentesis is the standard procedure for emergency pericardial drainage when ultrasound guidance is unavailable. Under these circumstances, puncture site and needle direction are exclusively oriented according to certain anatomic landmarks. In the literature, different techniques for this "blind" method have been described. Goal of this retrospective study was to compare the potential success and complication rate of 13 simulated puncture directions. METHODS: Simulated pericardiocentesis was performed in 150 CT scans from patients with moderate to severe pericardial effusions (greater than 1 cm distance between epicardium and pericardium). Thirteen different puncture techniques with varying puncture sites, direction of the puncture, and the angle were compared. A simulated pericardiocentesis was classified as "successful" when the effusion was reached. It was classified as "successful without a complication" when no adjacent structure was penetrated by the simulated puncture (lung, liver, internal thoracic artery, LAD, colon, and stomach). An attempt was declared as "unsuccessful" when the pericardial effusion was not reached at all, or the reached effusion measured less than 0.5 cm between the epicardium and pericardium at the location where the needle entered the pericardium. RESULTS: A subxiphoidal puncture technique starting in Larrey's triangle (sternocostal triangle) and directed toward the left midclavicular point with a 30° inclination resulted in the highest success rate (131 of 150 cases = 87%). In parallel the lowest complication rate (7 of 150 = 5%) was found using this technique, as well. In contrast, pericardiocentesis performed using other puncture directions resulted in lower success (66%-85%) and higher complication rates (9%-31%). CONCLUSION: This CT-based simulation study revealed that blind pericardiocentesis guided by anatomical landmarks only is best performed in a subxiphoid approach with a needle direction to the left midclavicular point with a 30° inclination. Nevertheless, injury of adjacent structures occurred frequently (5%) even when applying this puncture technique. Thus, blind pericardiocentesis can be performed with a high success rate and seems adequate to be performed under emergency conditions. However, planned procedures should be performed under image guidance.

Evolution of the pericardiocentesis technique.

: Pericardiocentesis is a valuable technique for the diagnosis and treatment of patients with pericardial effusion and cardiac tamponade, although it may be associated with potentially serious complications. Through the years, many different imaging approaches have been described to reduce the complication rate of the procedure. This systematic review provides a focused overview of the different techniques developed in recent years to reduce the procedural complications and to increase the related success rate.

Ultrasound-guided pericardiocentesis: a novel parasternal approach.

OBJECTIVE: The aim of this study was to evaluate a novel pericardiocentesis technique using an in-plane parasternal medial-to-lateral approach with the use of a high-frequency probe in patients with cardiac tamponade. BACKGROUND: Echocardiography is pivotal in the diagnosis of pericardial effusion and tamponade physiology. Ultrasound guidance for pericardiocentesis is currently considered the standard of care. Several approaches have been described recently, which differ mainly on the site of puncture (subxiphoid, apical, or parasternal). Although they share the use of low-frequency probes, there is absence of complete control of needle trajectory and real-time needle visualization. An in-plane and real-time technique has only been described anecdotally. METHODS AND RESULTS: A retrospective analysis of 11 patients (63% men, mean age: 37.7±21.2 years) presenting with cardiac tamponade admitted to the tertiary-care emergency department and treated with parasternal medial-to-lateral in-plane pericardiocentesis was carried out. The underlying causes of cardiac tamponade were different among the population. All the pericardiocentesis were successfully performed in the emergency department, without complications, relieving the hemodynamic instability. The mean time taken to perform the eight-step procedure was 309±76.4 s, with no procedure-related complications. CONCLUSION: The parasternal medial-to-lateral in-plane pericardiocentesis is a new technique theoretically free of complications and it enables real-time monitoring of needle trajectory. For the first time, a pericardiocentesis approach with a medial-to-lateral needle trajectory and real-time, in-plane, needle visualization was performed in a tamponade patient population.

Evaluation of Pericardial Effusion in Dogs and Successful Treatment Using a Hemodialysis Fistula Needle: A Retrospective Study.

The aim of this retrospective study was to assess epidemiology and echocardiographic findings of pericardial effusion in canine patients and to determine the clinical usefulness and safety of a new pericardiocentesis technique, using a "fistula needle" for hemodialysis. A database of 5304 dogs of different breeds, age, gender, type, and severity of the cardiac disease, referred for a specialist cardiology and echocardiographic examination from 2009-2016, was reviewed. All the dogs were subjected to echocardiography; when possible and required, an echo-guided pericardiocentesis was performed by mean of a 17G "fistula needle" commonly used for hemodialysis. Complete echocardiography was repeated at the end of each pericardiocentesis. Pericardial effusion was identified by echocardiography in 91 dogs (1.71%), 20 were female (21.98%) and 71 were male (78.02%). PE caused cardiac tamponade in 38/91 cases (41.76%). A clear evidence of a neoplasm was found in 33 cases (36.26%). In 32 cases (35.16%) severe degenerative mitral and tricuspid valve disease was detected as the cause of the pericardial effusion. Echo-guided pericardiocentesis was performed in 28 cases (30.77%) with cardiac tamponade. No adverse effects were found in any of the patients during the 48 hours of follow up after pericardiocentesis. This study showed the high incidence of pericardial effusion due to severe bilateral degenerative valve disease in adult to elderly dogs of different breeds. Moreover, the use of a "fistula needle" for pericardiocentesis in dogs showed no adverse effects.

Long-term peritoneal port-catheter in a patient with cardiac ascites.

A peritoneal port-catheter was inserted in a 70-year-old man because of repeated paracentesis due to cardiac ascites. Instead of frequent hospital admissions, the patient could drain his ascites at home, which dramatically improved his quality of life and enabled him to perform his daily activities.

Management of Tamponade Complicating Catheter Ablation for Atrial Fibrillation: Early Removal of Pericardial Drains Is Safe and Effective and Reduces Analgesic Requirements and Hospital Stay Compared to Conventional Delayed Removal.

OBJECTIVES: This study reports on the safety of early removal of pericardial drains after cardiac tamponade complicating atrial fibrillation catheter ablation (AFCA) procedures, the need for repeat pericardiocentesis, major adverse outcomes, as well as length of stay, and the need for opiate analgesia. BACKGROUND: Tamponade from AFCA is traditionally managed by pericardiocentesis with delayed removal of the drain (typically 12 to 24 h later) in case of re-bleeding. A drain in situ often causes severe pain but ongoing blood loss is rare. Our institution adopted the practice of early removal of drains before leaving the laboratory if bleeding has stopped. METHODS: The authors performed a retrospective descriptive analysis of 43 cases of tamponade complicating AFCA from 2006 to 2015, comparing patients in whom the drain was removed early (group early removal [ER]; n = 25) versus traditional delayed removal (group delayed removal [DR]; n = 18). RESULTS: The groups were similar with respect to clinical/demographic characteristics, proportions of first-time versus re-do and pulmonary vein isolation versus pulmonary vein isolation + additional ablation. There were no deaths. No ER patients required drain re-insertion before discharge. The length of stay was shorter in the ER group (3 days; range 1 to 9 days) than in the DR group (4 days; range 2 to 60 days). The requirement for opiate analgesia was less in the ER group (8%) than in the DR group (72%). CONCLUSIONS: Early removal of pericardial drains after tamponade complicating AFCA procedures appears to be safe and effective, with re-insertion not required in this cohort. The traditional practice of leaving drains in situ for 12 to 24 h may result in more patient discomfort and longer hospitalization.

Pericardiocentesis Under Continuous Ultrasonographic Guidance Using a 7 cm Micropuncture Needle.

OBJECTIVES: To compare procedural success and safety of pericardiocentesis using continuous ultrasonographic visualization of a long (7 cm) micropuncture needle to standard access with an 18 gauge needle without continuous ultrasound guidance. BACKGROUND: Current approaches to pericardiocentesis commonly utilize a large-bore 18 gauge needle for access without allowing for continuous visualization of needle entry into the pericardial space. METHODS: We included all consecutive patients at our institution who underwent pericardiocentesis between November 1, 2011 and March 3, 2016. A total of 21 patients (group 1) underwent pericardiocentesis using a 7 cm micropuncture needle inserted under continuous ultrasonographic guidance, while 51 patients (group 2) underwent pericardiocentesis, mostly with an 18 gauge needle (92%), following preprocedural echocardiography only. The primary endpoint was successful placement of a drain into the pericardial space. RESULTS: The primary endpoint was similar between group 1 and group 2 (100% vs 94%, respectively; P=.26). Successful drainage of pericardial fluid was achieved in 95% of patients in group 1 and in 98% in group 2 (P=.88). The amount of pericardial fluid drained in each group was similar (640 mL vs 557 mL, respectively; P=.26). No procedure-related complications occurred in group 1, compared with 2 cases of right ventricular perforation that occurred in group 2. In-hospital mortality and length of stay were similar. CONCLUSION: This study suggests that an ultrasound-mounted micropuncture needle allows for safe and effective pericardiocentesis. This technique may provide a safer alternative to the standard use of an 18 gauge needle.

The Parable of the Errant Chest Drain in the Heart: Is There Only 1 Option?

Accidental intraventricular placement of a pericardiocentesis catheter is a rare but well-recognized complication. Failure to achieve adequate hemostasis in the ventricular wall on removal of the catheter can potentially result in fatal consequences. Here we describe a case in which a chest drain (10.2F) accidentally entered into the right ventricle while attempting to drain pleural fluid, and the entry site was sealed using an Amplatzer VSD occluder device (St. Jude Medical, St. Paul, MN).

Ultrathin Endoscopy-Guided Pericardiocentesis: A Pilot Study in a Swine Model.

BACKGROUND: Pericardiocentesis under echocardiography guidance is a common procedure, but still poses a risk of injury to surrounding tissues. Nowadays, pericardiocentesis is being performed in patients with normal pericardium, for epicardial ablation or atrial appendage exclusion. Access to the normal pericardial space with the conventional needle procedure is very difficult. Thus, development of a novel method enabling safer pericardiocentesis is necessary. The present study aimed to assess the feasibility of using an originally developed ultrathin endoscopy-guided pericardiocentesis device in a swine model. METHODS AND RESULTS: We developed a novel ultrathin endoscopy-guided pericardiocentesis device. The device comprised a 1.2 mm ultrathin endoscope, a 20 G needle, and a grasping forceps. Pericardiocentesis was conducted as follows. A 12 Fr introducer sheath was inserted between the pericardium and the diaphragm under fluoroscopy. The pericardium was grasped with the originally developed forceps under endoscopy guidance to create a space in the pericardial sac. The 20 G needle was then inserted and a coiled-tip guidewire was placed into the pericardial sac. Five independent operators performed pericardiocentesis twice using this technique in a healthy pig with a body weight of approximately 25 kg. Procedural success rate and procedure time were assessed as the primary endpoints. The procedural success rate was 100% in all operators. The average procedure time was 65 ± 40 seconds (median, 46 seconds; interquartile range, 40-85 seconds). No procedure-related complications were noted. CONCLUSIONS: The study results indicate that ultrathin endoscopy-guided pericardiocentesis for normal pericardial space is feasible and safe.

Fractured pericardial drain sheath: Removal technique.

Pericardiocentesis with drain placement provides relief of symptomatic pericardial tamponade. The use of a pericardial sheath preserves access to the pericardial space in the event a drain may need to be replaced or manipulated. Although rare, sheath fracture and migration into the pericardial space may be a complication of prolonged sheath maintenance. Prompt action may allow percutaneous retrieval of the foreign body and avoid the need for surgical exploration. We report a case of successful percutaneous retrieval of a fractured pericardial sheath. © 2015 Wiley Periodicals, Inc.

Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: experience of a centre without cardiothoracic surgery.

BACKGROUND: Cardiac tamponade has been reported in 18.7% of patients with acute type A aortic dissection and its presence is associated with worse outcomes. Emergency aortic repair together with intra-operative pericardial drainage is the recommended treatment approach. However, controversy surrounds how to manage patients with haemopericardium and cardiac tamponade who cannot survive until surgery. PURPOSE: To describe a case series of patients with critical cardiac tamponade complicating aortic dissection admitted to a hospital without cardiothoracic surgery, and in whom preoperative controlled pericardial drainage was performed. METHODS AND RESULTS: Single centre retrospective study: during a nine-year period, 21 patients with Stanford type A aortic dissection were admitted at our centre; six of them (28.6%) presented clinical and echocardiographic signs of cardiac tamponade (four males; mean age 58±17 years). In this subgroup, controlled pericardiocentesis was safely performed with no major immediate complications and it was effective in five patients, improving haemodynamic instability and allowing transfer to the operating room. CONCLUSIONS: Preoperative controlled pericardiocentesis can be lifesaving when managing patients with critical cardiac tamponade (pulseless electrical activity or refractory hypotension) complicating acute type A aortic dissection, namely when cardiac surgery is not immediately available.